Long-term effectiveness and safety of didanosine combined with lamivudine and efavirenz or nevirapine in antiretroviral-naive patients: a 9-year cohort study in Senegal

Objective The use of didanosine (ddI) in first‐line antiretroviral therapy has been recently promoted for resource‐limited settings. We therefore compared the long‐term effectiveness and safety of the regimen combining ddI, lamivudine, and efavirenz or nevirapine with that of the WHO‐recommended regimen of zidovudine (ZDV), lamivudine, and efavirenz or nevirapine in antiretroviral‐naïve patients in Senegal. Methods Observational cohort study of patients enrolled between January 2000 and April 2002 in the Senegalese antiretroviral drug access initiative. Multivariate analyses were performed to compare, between the ddI and ZDV groups, the proportion of patients with a viral load <500 copies/ml during follow‐up; the increase in the CD4 cell count; survival; treatment changes and severe adverse events. Results Of 151 patients, 71 received the ddI‐based treatment and 80 received the ZDV‐based treatment. Throughout follow‐up, 80–95% of patients had a viral load below 500 copies/ml in both the ddI and ZDV groups (P = 0.5). The CD4 cell count increased after treatment initiation from 176 to 497 cells/mm³ in the ddI group and from 176 to 567 cells/mm³ in the ZDV group (P > 0.3). The rate of death tended to be higher in the ddI group (P = 0.06). ddI was less commonly discontinued than ZDV (P = 0.03). Conclusion The combination of ddI, lamivudine, and efavirenz or nevirapine resulted in sustained viral suppression and immunological recovery.     

An assessment of HIV testing in Tanzania to inform future strategies and interventions

This study identified characteristics of Tanzanians who have never tested for HIV in order to inform localized interventions to increase HIV testing coverage and uptake. A total of 3257 randomly selected participants aged 18–49 years were surveyed in 16 Mainland regions. Those surveyed were asked about demographics, HIV risk perception, HIV testing behavior, knowledge of both their own and partner's HIV status, and if they were tested with their partner. Approximately 22% of women and 46% of men reported never testing for HIV, with those who are younger (18–24 years), single/never married, living in rural areas, less educated, and having multiple sexual partners in the past year less likely to have tested. The gender differences in HIV testing behavior identified are supported by existing research. No association was found in either gender between HIV risk perception and testing, however, those least likely to test were those with multiple sex partners. These findings can help better target localized interventions focused on younger, single people, and those with multiple sex partners.     

Short Communication: Low seroprevalence of cryptococcal antigenaemia in patients with advanced HIV infection enrolling in an antiretroviral programme in Ghana

Objectives To determine the prevalence of cryptococcal antigenaemia in a clinic population with advanced HIV infection, with a view to giving antifungal therapy to those testing positive. Methods Serum samples from adults with CD4 count <100 cells/mm³ presenting to a large HIV clinic in Kumasi, Ghana, were tested retrospectively for cryptococcal antigenaemia using a latex agglutination assay, and clinical and demographic data extracted from case notes. Results Of 92 samples tested, two were positive thus giving a prevalence of 2% (95% CI, 0–5.2%). Conclusions The prevalence of cryptococcal antigenaemia in patients with advanced HIV infection enrolling in an antiretroviral programme appears to be low in Kumasi, suggesting that the value of routine testing of outpatients diagnosed with advanced HIV infection may be limited in this population.     

Invasive bacterial and fungal infections among hospitalized HIV-infected and HIV-uninfected children and infants in northern Tanzania

Objective To describe the contribution of paediatric HIV and of HIV co‐infections to admissions to a hospital in Moshi, Tanzania, using contemporary laboratory methods. Methods During 1 year, we enrolled consecutively admitted patients aged ≥2 months and <13 years with current or recent fever. All patients underwent standardized clinical history taking, a physical examination and HIV antibody testing; standard aerobic blood cultures and malaria film were also done, and hospital outcome was recorded. Early infant HIV diagnosis by HIV‐1 RNA PCR was performed on those aged <18 months. HIV‐infected patients also received serum cryptococcal antigen testing and had their CD4‐positive T‐lymphocyte count and percent determined. Results A total of 467 patients were enrolled whose median age was 2 years (range 2 months–13 years); Of those patients, 57.2% were female and 12.2% were HIV‐infected. Admission clinical diagnosis of HIV disease was made in 10.7% and of malaria in 60.4%. Of blood cultures, 5.8% grew pathogens; of these 25.9% were Salmonella enterica (including 6 Salmonella Typhi) and 22.2%Streptococcus pneumoniae. Plasmodium falciparum was identified on blood film of 1.3%. HIV infection was associated with S. pneumoniae (odds ratio 25.7, 95% CI 2.8, 234.0) bloodstream infection (BSI), but there was no evidence of an association with Escherichia coli or P. falciparum; Salmonella Typhi BSI occurred only among HIV‐uninfected participants. The sensitivity and specificity of an admission clinical diagnosis of malaria were 100% and 40.3%; and for an admission diagnosis of bloodstream infection, they were 9.1% and 86.4%, respectively. Conclusion Streptococcus pneumoniae is a leading cause of bloodstream infection among paediatric admissions in Tanzania and is closely associated with HIV infection. Malaria was over‐diagnosed clinically, whereas invasive bacterial disease was underestimated. HIV and HIV co‐infections contribute to a substantial proportion of paediatric febrile admissions, underscoring the value of routine HIV testing.     

Individual, household and community factors associated with HIV test refusal in rural Malawi

Objective To investigate individual, household and community factors associated with HIV test refusal in a counselling and testing programme offered at population level in rural Malawi. Methods HIV counselling and testing was offered to individuals aged 18–59 at their homes. Individual variables were collected by interviews and physical examinations. Household variables were determined as part of a previous census. Multivariate models allowing for household and community clustering were used to assess associations between HIV test refusal and explanatory variables. Results Of 2303 eligible adults, 2129 were found and 1443 agreed to HIV testing. Test refusal was less likely by those who were never married [adjusted odds ratio (aOR) 0.50 for men (95% CI 0.32; 0.80) and 0.44 (0.21; 0.91) for women] and by farmers [aOR 0.70 (0.52; 0.96) for men and 0.59 (0.40; 0.87) for women]. A 10% increase in cluster refusal rates increased the odds of refusal by 1.48 (1.32; 1.66) in men and 1.68 (1.32; 2.12) in women. Women counsellors increased the odds of refusal by 1.39 (1.00; 1.92) in men. Predictors of HIV test refusal in women were refusal of the husband as head of household [aOR 15.08 (9.39; 24.21)] and living close to the main road [aOR 6.07 (1.76; 20.98)]. Common reasons for refusal were fear of testing positive, previous HIV test, knowledge of HIV serostatus and the need for more time to think. Conclusion Successful VCT strategies need to encourage couples counselling and should involve participation of men and communities.     

Disease profile of children under 5 years attending primary health care clinics in a high HIV prevalence setting in South Africa

Objective To describe the presenting complaints and disease profile of children attending primary health care (PHC) clinics in two provinces of South Africa. Methods Participants were sick children 2–59 months old presenting for care at PHC clinics in KwaZulu‐Natal (KZN) and Limpopo provinces from 2006–2007. Children were assessed by an expert Integrated Management of Childhood Illnesses (IMCI) practitioner. Children for whom parental/guardian consent was obtained were tested for HIV. Results A total of 1357 children attending one of 74 clinics were assessed. HIV seroprevalence overall was 7.1%, but was significantly higher in KZN than Limpopo (7.5 vs. 2.4%; OR = 3.3, 95%CI 1.9–5.8%). Commonest presenting complaints were cough (72%), skin conditions (22%) and diarrhoea (19%). Of 1349 children, 120 (8.9%) had a weight below the third percentile; 108/1357 (8.0%) children required urgent referral, most commonly for severe pneumonia (53.7%) and severe malnutrition (16.7%). In multivariate analyses, severe pneumonia, growth faltering and urgent referral were independently associated with younger age, residence in KZN and HIV infection (P < 0.05). Conclusions Many children with severe illnesses and undiagnosed HIV infection present to PHC facilities. PHC staff require skills to correctly manage these conditions and undertake HIV testing. Although IMCI provides evidence‐based guidelines, implementation must be improved to achieve adequate coverage of life‐saving interventions.     

High prevalence of stigma-related abuse among a sample of men who have sex with men in Tanzania: implications for HIV prevention

In sub-Saharan Africa, the prevalence of stigma-related abuse and violence among men who have sex with men (MSM) and its potential impact on the HIV/AIDS epidemic is unknown. This study estimated the prevalence and source of violence and abuse among a sample of MSM in Tanzania and characterized the association between levels of violence and sexual and mental health variables. Data were taken from a larger study of 200 MSM in Tanzania. Frequency tabulations, bivariate analysis, and logistic regression were performed to describe the prevalence and source of abuse and to determine the association between levels of violence and sexual demographics and mental health variables. The MSM sample for this study was young (median age 23), somewhat educated with the majority having attained secondary school (80%) and mostly employed (60%). Verbal (48.5%) and moral (32.5%) abuses were the most predominant types of abuse among the sample and were mostly from people in the street and neighbors. Sexual abuse (30%) was mostly from partners, and physical violence (29.5%) was largely from people in the street. Participants in the high-violence level group had a significantly greater number of sexual partners, depression scores, and internalized homonegativity (IH) scores. IH predicted HIV infection and verbal abuse predicted IH.There is a need for an increased awareness of violence and abuse faced by MSM in Tanzania, as well as effective programs to specifically target the issue of violence among MSM, and its implication for mental health and for risky sexual behaviors and HIV transmission.     

Challenges to ART scale‐up in a rural district in Tanzania: stigma and distrust among Tanzanian health care workers,people living with HIV and community members

Objective To explore attitudes, perceptions and practices among health care workers, antiretroviral treatment (ART) patients and community members regarding ART care and the social consequences of ART roll‐out in rural Tanzania. Methods We performed focus group discussions and in‐depth interviews with health care workers, community members, ART patients, religious leaders, as well as social workers. Field observations and ethnographic assessments were conducted in parallel. Results We found widespread negative attitudes and perceptions of ART care HIV testing and the ART programme, a lack of trust in its sustainability, as well as lack of community and health worker involvement in the programme planning and treatment. HIV‐positive individuals on ART reported risky behaviours with the aim of revenge and were feared by community members. We also found that the ART availability was seen as an incentive to engage in HIV testing among some community members. Conclusion Our findings underline the importance of involving health workers and the community at a high level and their important role in promoting trust in the ART programme. There is an immense need to adjust interventions focusing on stigma reduction in the direction of ART scale‐up and to build awareness among ART patients so they understand how risky behaviours affect their personal well‐being and the community at large.     

Hypertension burden and challenges across the hypertension treatment cascade among adults enrolled in HIV care in northern Tanzania

Failure to address hypertension among people living with HIV (PLWH) may undermine the significant progress made toward reducing mortality among this high‐risk population in sub‐Saharan Africa (SSA). Here, the authors report hypertension prevalence, diagnosis, and treatment among patients enrolled in HIV care in Tanzania. Patients attending an HIV clinic were consecutively screened for hypertension. Hypertension was defined as follows: a single blood pressure measurement ≥160 mm Hg systolic or ≥100 mm Hg diastolic, two measurements at separate visits ≥140 mm Hg systolic or ≥90 mm Hg diastolic, or self‐reported hypertension diagnosis. The authors screened 555 patients, and 19.6% met hypertension criteria. Among a subset of 91 hypertensive participants, 44 (48.4%) reported previous blood pressure measurements, 32 (35.2%) were aware of diagnosis, 10 (11.0%) reported current antihypertensive use, and none had controlled blood pressure. Addressing barriers along the hypertension treatment cascade must be a top priority to improve cardiovascular outcomes among PLWH in SSA.     

Levels of childhood vaccination coverage and the impact of maternal HIV status on child vaccination status in rural KwaZulu‐Natal,South Africa*

Objectives To analyse coverage of childhood vaccinations in a rural South African population and investigate whether maternal HIV status is associated with children’s vaccination status. Methods 2 431 children with complete information, 12–23 months of age at some point during the period January 2005 through December 2006 and resident in the Africa Centre Demographic Surveillance Area at the time of their birth were investigated. We examined the relationship between maternal HIV status and child vaccination status for five vaccinations [Bacillus Calmette‐Guérin (BCG), diphtheria‐tetanus‐pertussis (DTP3), poliomyelitis (polio3), hepatitis B (HepB3), and measles] in multiple logistic regressions, controlling for household wealth, maternal age, maternal education and distances to roads, fixed and mobile clinics. Results Coverage of the five vaccinations ranged from 89.3% (95% CI 81.7–93.9) for BCG to 77.3% (67.1–83.6) for measles. Multivariably, maternal HIV‐positive status was significantly associated with lower adjusted odds ratios (AOR) of child vaccination for all vaccines [(AOR) 0.60–0.74, all P ≤ 0.036] except measles (0.75, P = 0.073), distance to mobile clinic was negatively associated with vaccination status (all P ≤ 0.029), household wealth was positively (all P ≤ 0.013) and distance to nearest road negatively (all P ≤ 0.004) associated with vaccination status. Conclusion Positive maternal HIV status independently reduces children’s probability to receive child vaccinations, which likely contributes to the morbidity and mortality differential between children of HIV‐positive and HIV‐negative mothers. As a means of increasing vaccination coverage, policy makers should consider increasing the number of mobile clinics in this and similar communities in rural Africa.     

Quality care: a link between clinical and public health approaches to HIV infection in developing countries

As the importance of quality in health care provision is increasingly recognised, it is opportune to consider quality care as a key link between clinical and public health approaches to human immunodeficiency virus (HIV) infection in developing countries, especially in sub‐Saharan Africa. This region has the lion’s share of the global epidemic and the least resources to respond. Looking at health problems using a ‘quality lens’ may help bridge the gaps between clinical care and public health, the current and desired standard of care, and prevention and treatment. Quality care, with prompt diagnosis and effective treatment, of people with HIV infection is crucial for good individual health outcomes, public health outcomes (in terms of decreased HIV transmission) and societal outcomes (increased productivity and decreased costs of health provision for HIV‐related care). A spotlight on quality care can bring clinicians and public health practitioners together in working towards universal access to quality HIV care and prevention – one of the greatest health challenges faced in developing countries in Africa today.     

Nocturnal dipping of heart rate and blood pressure in people with HIV in Tanzania

People with HIV (PWH) have a >2‐fold greater risk for development of cardiovascular disease (CVD), which may be associated with abnormalities in 24‐h ambulatory blood pressure measurement (ABPM) profile. We conducted a nested case‐control study of ABPM in 137 PWH and HIV‐uninfected controls with normal and high clinic blood pressure (BP) in Tanzania. Nocturnal non‐dipping of heart rate (HR) was significantly more common among PWH than HIV‐uninfected controls (p = .01). Nocturnal non‐dipping of BP was significantly more common in PWH with normal clinic BP (p = .048). Clinical correlates of nocturnal non‐dipping were similar in PWH and HIV‐uninfected adults and included higher BMI, higher CD4⁺ cell count, and high C‐reactive protein for HR and markers of renal disease for BP. In conclusion, nocturnal non‐dipping of both BP and HR was more common in PWH but further research is needed to determine causes and consequences of this difference.     

Benefit of viral load testing for confirmation of immunological failure in HIV patients treated in rural Malawi

Objective Viral load testing is used in the HIV programme of Chiradzulu, Malawi, to confirm the diagnosis of immunological failure to prevent unnecessary switching to second‐line therapy. Our objective was to quantify the benefit of this strategy for management of treatment failure in a large decentralized HIV programme in Africa. Methods Retrospective analysis of monitoring data from adults treated with first‐line antiretroviral regimens for >1 year and meeting the WHO immunological failure criteria in an HIV programme in rural Malawi. The positive predictive value of using immunological failure criteria to diagnose virological failure (viral load >5000 copies/ml) was estimated. Results Of the 227 patients with immunological failure (185 confirmed with a repeat CD4 measurement), 155 (68.2%) had confirmatory viral load testing. Forty‐four (28.4%) had viral load >5000 copies/ml and 57 (36.8%) >1000 copies/ml. Positive predictive value was 28.4% (95% CI 21.4–36.2%). Repeat CD4 count testing showed that 41% of patients initially diagnosed with immunological failure did no longer meet failure criteria. Conclusions Our results support the need for confirming all cases of immunological failure with viral load testing before switching to second‐line ART to optimize the use of resources in developing countries.     

Recurrent costs of HIV/AIDS-related health services in Rwanda: implications for financing

Objective To estimate recurrent costs per patient and costs for a national HIV/AIDS treatment programme model in Rwanda. Methods A national HIV/AIDS treatment programme model was developed. Unit costs were estimated so as to reflect necessary service consumption of people living with HIV/AIDS (PLWHA). Two scenarios were calculated: (1) for patients/clients in the year 2006 and (2) for potential increases of patients/clients. A sensitivity analysis was conducted to test the robustness of results. Results Average yearly treatment costs were estimated to amount to 504 US$ per patient on antiretroviral therapy (ART) and to 91 US$ for non‐ART patients. Costs for the Rwandan HIV/AIDS treatment programme were estimated to lie between 20.9 and 27.1 million US$ depending on the scenario. ART required 9.6 to 11.1 million US$ or 41–46% of national programme costs. Treatment for opportunistic infections and other pathologies consumed 7.1 to 9.3 million US$ or 34% of total costs. Conclusion Health Care in general and ART more specifically is unaffordable for the vast majority of Rwandan PLWHA. Adequate resources need to be provided not only for ART but also to assure treatment of opportunistic infections and other pathologies. While risk‐pooling may play a limited role in the national response to HIV/AIDS, considering the general level of poverty of the Rwandan population, no appreciable alternative to continued donor funding exists for the foreseeable future.     

Determinants of unplanned antiretroviral treatment interruptions among people living with HIV in Yaoundé, Cameroon (EVAL survey,ANRS 12‐116)

Objective To identify correlates of self‐reported antiretroviral therapies (ART) interruptions among people living with HIV and AIDS (PLWHA) in Cameroon. Methods Analyses were based on data collected in the national survey EVAL (ANRS 12‐116) among 533 ART‐treated PLWHA in Yaoundé, the capital city of Cameroon, and its neighbourhood. Logistic regression models were used to identify factors associated with self‐reported ART interruptions longer than two consecutive days during the previous 4 weeks. Results ART interruptions were reported by 68 patients (12.8%). After adjustment for gender, education and household income, characteristics independently associated with interruptions were pharmacy stock shortages [OR (95%CI):3.25 (1.78–5.90)], binge drinking [2.87 (1.39–5.91)] and the number of self‐reported slimming symptoms [1.23 (1.02–1.48)]. Conclusion In poor‐resource settings where access to second and third‐line regimens is still limited, food supply programs and interventions to minimise ART shortage may reduce the risk of ART interruptions.     

Prevalence and factors associated with alcohol drinking among HIV and tuberculosis co-infected patients in Dar es Salaam,Tanzania

There is scarcity of information on the burden of alcohol use among people living with HIV in Tanzania despite the high burden of HIV. We examined the prevalence and factors associated with alcohol use among HIV and tuberculosis (TB) co-infected patients in fourteen clinics with highest notification of TB in Dar es Salaam, Tanzania, between October 2010 and December 2011. Proportions were used to describe the prevalence and pattern of alcohol use. Logistic regression was used to assess the association of various participant characteristics with alcohol use. Out of the 515 participants, 38 (7.4%) were current alcohol drinkers, 183 (35.5%) were ex-drinkers and the rest, 294 (57.1%) denied ever drinking alcohol. Approximately, 15% of past and current drinkers were classified as heavy drinkers. Patients with normal BMI, cigarette smokers, and those with higher income were more likely to be drinkers. Similarly, compared to civil servants, those in petty trade and other occupations were more likely to be drinkers. We concluded that, the level of current alcohol use among HIV positive people receiving pulmonary TB treatment in this population was low. Nevertheless, alcohol use screening and assessment should be added as an integral part of service provision in HIV clinics given the effect of alcohol on health outcomes among HIV positive patients.